Management of Labour Flashcards
A primigravida presents in term labour, 39/40, at 4cm, planning vaginal breech delivery. Contraction frequency is regular and there are no CTG concerns. Some 4 hours later you are called to review the CTG. There is a baseline rate of 145 bpm with reduced variability for the last 60 minutes and repetitive decelerations, some of which appear late. You perform a vaginal examination and find the cervix 6cm, buttocks presenting at -1 above ischial spines. What management do you recommend?
a. Delivery by caesarean section Cat. 1
b. Delivery by caesarean section Cat. 2
c. FBS
d. Oxytocin augmentation
e. Give fluids, change position and review the CTG in 30 minutes
B - Delivery by caesarean section Cat. 2
This scenario describes acceptable labour progress though in the context of a pathological CTG (>50 minutes reduced variability, late decelerations). While in a cephalic labour, a trial of conservative measures or FBS to further assess the fetal condition may be performed, neither are appropriate with a breech baby (though FBS of the buttocks is technically possible, it is not recommended). While judicious use of oxytocin for purposes of augmentation may be considered in breech labours, it is neither indicated here nor appropriate with such a CTG. The guideline states that ‘where EFM is considered abnormal before the active second stage, caesarean delivery is recommended’ – a category 2 would be appropriate in this scenario.
A Para 3 presents in labour un-booked, with no history of antenatal care in this pregnancy. She has had 3 previous vaginal deliveries and on examination appears to be in established labour at 5cm though membranes are intact. SFH is recorded as 38cm. You note the presence of herpetic lesions on the external genitalia which the patient informs you appeared 7 days ago and she has no recollection of having had genital herpes in the past. What management do you suggest?
a. Delivery by Cat. 1 LSCS
b. Delivery by Cat. 2 LSCS
c. As labour established and multiparous, vaginal delivery under IV acyclovir cover
d. Providing expected progress is made on subsequent examination, vaginal delivery with acyclovir for the neonate at birth
e. Providing expected progress is made on subsequent examination, vaginal delivery with IV acyclovir for both patient and neonate at birth
B - Delivery by Cat. 2 LSCS
This history is suggestive of primary genital HSV infection and delivery by caesarean section is the preferred mode of delivery here. There is still some benefit to be gained despite active labour already having started, particularly as membranes are intact. There is no immediate threat to the life of the mother nor her fetus therefore a Cat. 2 caesarean would be most appropriate.
A patient with a history of primary genital herpes in the third trimester is quite adamant after counselling, that she wishes to proceed with vaginal birth. What intrapartum regimen of acyclovir so you advise during labour?
a. 400mg 8 hourly orally
b. 400mg 8 hourly IV
c. 800mg 5x/day orally
d. 5mg/kg 8 hourly IV
e. 20mg/kg 8 hourly IV
D - 5mg/kg IV 8-hourly
5mg/kg IV 8-hourly is the recommended dose of acyclovir for patients with a primary episode in the third trimester or last 6 weeks who wish to proceed with vaginal delivery. Equivalent to 300mg in a 60kg patient.
A primigravida presents with membrane rupture at 37+4/40 though does not appear to be in active labour. You note the results of a HVS performed earlier in the pregnancy which demonstrated GBS carriage. What is the most appropriate management in this case?
a. Administer erythromycin 250mg QDS and offer IOL in 24 hours if not in spontaneous labour
b. IOL in 24 hours if no spontaneous labour
c. Commence IV Benzylpenicillin at the usual dose and offer IOL in 4-6 hours if no contractions in the meantime
d. Commence IV Benzylpenicillin at the usual dose and offer immediate IOL
e. Advise delivery by Cat 2 LSCS
D - Commence IV Benzylpenicillin and offer immediate induction of labour
Routine management here in the absence of GBS would be to offer induction of labour in 24 hours if the woman does not labour spontaneously – in the context of known GBS carriage (or another indication for IAP), it is prudent to expedite this and proceed with IOL immediately.
What is the dose of Benzylpenicillin for intrapartum antibiotic prophylaxis in GBS?
a. 4 gram stat and 1 gram 4 hourly IV
b. 1.5 grams 4 hourly IV
c. 3 grams stat and 1 gram 6 hourly IV
d. 3 grams state and 1.5 grams 4 hourly IV
e. 1.5 grams stat and 1 gram 4 hourly IV
D - 3 grams state and 1.5 grams 4 hourly IV
The recommended antibiotic course for GBS prophylaxis is labour is 3 grams of Benzylpenicillin as a loading dose, then 1.5grams every 4 hours until delivery thereafter.
A primigravida, known to be GBS positive after opportunistic testing earlier in pregnancy arrives on delivery suite at 38/40 in spontaneous labour. You note from her hand-held maternity record that she has an allergy to penicillin. On discussing this further with the patient she discloses that on a few occasions after taking amoxicillin for urinary infections, she has developed an itch. Which antibiotic protocol do you suggest?
a. Benzylpenicillin – 3 grams loading and 1.5 grams 4 hourly
b. Cefuroxime 1.5 grams 8 hourly
c. Vancomycin 1 gram 12 hourly
d. Gentamicin 300mg 24 hourly
e. Erythromycin 250mg QDS
B - Cefuroxime 1.5 grams 8 hourly
Antibiotic choice for GBS prophylaxis in the context of penicillin allergy depends on the nature/severity of the allergy. If on questioning the reaction described is unlikely to represent a true allergy – i.e. vomiting – then the penicillin should be given. If suggestive of an allergy to beta-lactams, but one that is not severe
(i.e. no anaphylaxis, angioedema, respiratory distress or urticaria), then a cephalosporin can be administered intravenously (e.g. cefuroxime, 1.5 g loading dose followed by 750 mg every 8 hours). If the allergy to beta-lactams is
severe then intravenous vancomycin (1 g every 12 hours) is recommended.
A Para 3, known to be GBS positive after opportunistic testing earlier in pregnancy arrives on delivery suite at 38/40 in spontaneous labour. You note from her hand-held maternity record that she has an allergy to penicillin. On discussing this further with the patient she discloses that the last time she had a UTI, she vomited after taking amoxicillin though thinks she had taken it in the past without a problem. Which antibiotic protocol do you suggest?
a. Benzylpenicillin – 3 grams loading and 1.5 grams 4 hourly
b. Cefuroxime 1.5 grams 8 hourly
c. Vancomycin 1 gram 12 hourly
d. Gentamicin 300mg 24 hourly
e. Erythromycin 250mg QDS
A - Benzylpenicillin 3 grams loading and 1.5 grams 4 hourly
Antibiotic choice for GBS prophylaxis in the context of penicillin allergy depends on the nature/severity of the allergy. If on questioning the reaction described is unlikely to represent a true allergy – i.e. vomiting – then the penicillin should be given. If suggestive of an allergy to beta-lactams, but one that is not severe
(i.e. no anaphylaxis, angioedema, respiratory distress or urticaria), then a cephalosporin can be administered intravenously (e.g. cefuroxime, 1.5 g loading dose followed by 750 mg every 8 hours). If the allergy to beta-lactams is
severe then intravenous vancomycin (1 g every 12 hours) is recommended.
A Para 1 attends delivery suite in preterm labour at 34+3/40 with ruptured membranes. On review, you note that a swab taken at 12/40 during an admission with threatened miscarriage was negative for infection or significant culture. The patient’s handheld maternity record also discloses a history of severe penicillin allergy in infancy with anaphylactic shock. What antibiotic prophylaxis, if any, do you advise in labour?
a. No prophylaxis necessary
b. Cefuroxime 1.5 grams 8 hourly
c. Vancomycin 1 gram 12 hourly
d. Gentamicin 300mg 24 hourly
e. Erythromycin 250mg QDS
C - Vancomycin 1 gram 12 hourly
Antibiotic choice for GBS prophylaxis in the context of penicillin allergy depends on the nature/severity of the allergy. If on questioning the reaction described is unlikely to represent a true allergy – i.e. vomiting – then the penicillin should be given. If suggestive of an allergy to beta-lactams, but one that is not severe
(i.e. no anaphylaxis, angioedema, respiratory distress or urticaria), then a cephalosporin can be administered intravenously (e.g. cefuroxime, 1.5 g loading dose followed by 750 mg every 8 hours). If the allergy to beta-lactams is
severe then intravenous vancomycin (1 g every 12 hours) is recommended.
A patient attends the delivery suite in early labour, though is struggling with pain and requests an epidural. Owing to her VTE risk assessment score of 3, she has been on antenatal LMWH thromboprophylaxis which she last took at 6 o’clock last night. It is now 9am. How long after a dose of prophylactic LMWH can regional anaesthetic safely be sited?
a. 4 hours
b. 6 hours
c. 12 hours
d. 18 hours
e. 24 hours
C - 12 hours
Regional analgesia should – wherever possible – be avoided until at least 12 hours from the last prophylactic dose of LMWH. For this reason (amongst others), women are often advised to omit a dose if they believe labour to be starting. Alternatives such as an opiate based PCA may be offered to those in whom LMWH dosing precludes epidural analgesia.
A patient attends the delivery suite in early labour, though is struggling with pain and requests an epidural. After developing a DVT at 32/40, she has been on treatment dose LMWH which she last took at 6 o’clock last night. It is now 9am. How long after a treatment dose of LMWH can regional anaesthetic safely be sited?
a. 6 hours
b. 12 hours
c. 24 hours
d. 36 hours
e. 48 hours
C - 24 hours
Following a treatment dose of LMWH, regional analgesia should be avoided where possible for 24 hours. It may be reasonable in certain circumstances to offer induction of labour to patients on treatment (or high-prophylactic) dose LMWH in order to facilitate pain relief options around delivery.
A midwife is attending a women in early labour at home. Auscultation of the fetal heart immediately after SROM reveals a prolonged bradycardia with the FHR at 90bpm. A vaginal examination in performed and the umbilical cord found to be prolapsed beyond the fetal head through an incompletely dilated cervix (6cm). Urgent hospital transfer is arranged. Which of the following conservative methods should NOT be used in this patient?
a. Bladder filling with 750ml sterile water
b. Maternal left lateral position
c. Terbutaline 0.25 micrograms s/c
d. Manual replacement of the cord
e. Manual displacement of the fetal head
D - Manual replacement of the cord
When cord prolapse is diagnosed, the priority for immediate management should be seek assistance and plan immediate delivery in theatre. While in the inpatient setting, manual elevation of the presenting part may be all that is required while awaiting transfer, the midwife encountering cord prolapse at a homebirth may need to give consideration to additional measures – filling the bladder with 500-750ml of sterile water to elevate the fetal head, administration of tocolytic terbutaline and adoption of the knee-chest or left lateral position (with a pillow under the left hip) are all described and may be of benefit. One method which should not be employed however is attempting manual replacement of the cord to permit continuation of labour. Handling loops of cord outwith the vagina can induce vasospasm, further restricting fetal blood flow.
What is the effect on the average time of labour with the additional of 200mg mifepristone to a misoprostol regimen for intra-uterine fetal death?
a. No change
b. Reduces by 2 hours
c. Reduces by 4 hours
d. Reduces by 7 hours
e. Reduces by 9 hours
D - Reduces by 7 hours
There is evidence to suggest that the addition of mifepristone to misoprostol induction of labour regimens may shorten the time interval between induction and delivery by approximately 7 hours though there is no other apparent benefit with its use. A single dose of mifepristone 200mg is appropriate for this indication.
What is the recommended induction regimen for women with IUFD beyond 27/40?
a. Misoprostol 25mg 8 hourly
b. Misoprostol 400mcg 8 hourly
c. Misoprostol 50mcg 4 hourly
d. Misoprostol 200mcg 3 hourly
e. Misoprostol 100mcg 6 hourly
C - Misoprostol 50mcg 4 hourly
The use of misoprostol in pregnancy in the UK is off-label though its role for IOL in IUFD is endorsed by NICE. Vaginal administration is as effective as oral though with a lower incidence of adverse side-effects. The suggested doses are as follows:
- Up to and including 26+6/40: 100 micrograms 6 hourly
- From 27+0/40 onwards: 50mcg 4 hourly
Both regimens are suggested for up to 24 hours, as required.
What is the recommended induction regimen for women with IUFD <26+6?
a. Misoprostol 25mg 6 hourly
b. Misoprostol 400mcg 8 hourly
c. Misoprostol 50mcg 4 hourly
d. Misoprostol 200mcg 3 hourly
e. Misoprostol 100mcg 6 hourly
E - Misoprostol 100mcg 6 hourly
The use of misoprostol in pregnancy in the UK is off-label though its role for IOL in IUFD is endorsed by NICE. Vaginal administration is as effective as oral though with a lower incidence of adverse side-effects. The suggested doses are as follows:
- Up to and including 26+6/40: 100 micrograms 6 hourly
- From 27+0/40 onwards: 50mcg 4 hourly
Both regimens are suggested for up to 24 hours, as required.
Titrated oxytocin is now the commonest adjunct used for induction of labour and maintaining uterine contractions. What is the mechanism of action of oxytocin?
a. Increases prostaglandin release from the chorioamniotic membrane
b. Increases release of interleukin 6 and 8 from the amniochoriodecidual space
c. Binding to oxytocin receptors in the uterus resulting in myometrial contractility
d. Acting directly on the cervix causing it to soften and dilate
e. Acting on receptors on the nipples uterus and cervix to cause contractions, cervical dilatation and effacement
C - Binding to oxytocin receptors in the uterus resulting in myometrial contractility
What is the most common reason for transfer from midwifery-led to obstetric-led care in labour?
a. Concern regarding fetal heart rate
b. Meconium passage
c. Failure to progress
d. Perineal trauma
e. Request for regional analgesia
C - Failure to progress
A low risk primigravida presents in early labour for assessment. What should be the nature of fetal monitoring undertaken as part of this assessment?
a. Computerised CTG until criteria met
b. Non-computerised CTG for 20 minutes
c. Auscultation of fetal heart for 30 seconds immediately after a contraction
d. Auscultation of fetal heart for 60 seconds immediately after a contraction
e. Auscultation of fetal heart during and for 30 seconds after a contraction
D - Auscultation of the fetal heart for 60 seconds immediately after a contraction
A patient booked for midwifery led care is assessed in her local birthing unit. On arrival her blood pressure is noted to be elevated at 155/95mmHg. Urine dipstick testing is negative for protein. What action should be taken here?
a. Commence 5-minute interval BP checks
b. Repeat BP in 30 minutes
c. Repeat BP in 60 minutes
d. Arrange immediate transfer to obstetric led car
e. Administer anti-hypertensives and arrange transfer to obstetric led care
B - Repeat BP in 30 minutes
A 41 year old primigravida (IVF pregnancy) with a booking BMI of 35, is assessed upon arrival at her local midwifery-led birthing unit in labour at 37+5/40. The fetus is cephalic, 5/5 palpable per abdomen and the fetal heart rate on auscultation is 115/min. Results of a recent full blood count are reviewed on which Hb is noted to be 90g/L. What aspect of this history should prompt transfer to obstetric led intrapartum care?
a. Maternal age
b. IVF pregnancy
c. BMI
d. Fetal engagement
e. Hb
D - Fetal engagement
What is the maximum water temperature advised for women who request immersion in water during labour?
a. 30C
b. 37.5C
c. 40C
d. 45C
e. 50C
B - 37.5C
How often should water temperature be checked where a patient is labouring in water?
a. Every 10 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every hour
e. When water is initially drawn, no need to check thereafter if within recommended range
D - Every hour
A patient receives 100mg of pethidine during the first stage of labour. Shortly afterwards she requests immersion in water. How long after receiving opioid analgesia should patients wait prior to entering water during labour?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 2 hours
e. No restrictions
D - 2 hours
How long after insertion of epidural analgesia should anaesthetic opinion be sought if patients are not pain free?
a. 5 minutes
b. 10 minutes
c. 15 minutes
d. 30 minutes
e. 45 minutes
D - 30 minutes
How often should the level of sensory block be checked during labour in women with regional analgesia?
a. Every 15 minutes
b. Every 30 minutes
c. Every hour
d. Every 2 hours
e. Every 3 hours
C - Every hour
What frequency of intermittent auscultation is advised in low risk women during the first stage of labour?
a. 60 seconds after every contraction
b. 60 seconds after a contraction every 10 minutes
c. 30 seconds after every contraction
d. 30 seconds after a contraction every 10 minutes
e. 30 seconds after a contraction every 15 minutes
B - 60 seconds after a contraction every 10 minutes
After which time period on intrapartum CTG does decreased variability become a non-reassuring feature?
a. 20 minutes
b. 30 minutes
c. 40 minutes
d. 50 minutes
e. 60 minutes
B - 30 minutes
After which time period on intrapartum CTG does decreased variability become an abnormal feature?
a. 40 minutes
b. 50 minutes
c. 60 minutes
d. 90 minutes
e. 120 minutes
B - 50 minutes
After which time period on intrapartum CTG does increased variability (>25/min) variability become a non-reassuring feature?
a. 15 minutes
b. 30 minutes
c. 45 minutes
d. 60 minutes
e. 90 minutes
A - 15 minutes
